Article

Is Bipolar Disorder Overdiagnosed?

Department of Psychiatry and Human Behavior, Brown Medical School, and Rhode Island Hospital, Providence, RI, USA.
The Journal of Clinical Psychiatry (Impact Factor: 5.5). 05/2008; 69(6):935-40. DOI: 10.4088/JCP.v69n0608
Source: PubMed

ABSTRACT

Bipolar disorder, a serious illness resulting in significant psychosocial morbidity and excess mortality, has been reported to be frequently underdiagnosed. However, during the past few years we have observed the emergence of an opposite phenomenon--the overdiagnosis of bipolar disorder. In the present report from the Rhode Island Methods to Improve Diagnostic Assessment and Services (MIDAS) project, we empirically examined whether bipolar disorder is overdiagnosed.
Seven hundred psychiatric outpatients were interviewed with the Structured Clinical Interview for DSM-IV (SCID) and completed a self-administered questionnaire, which asked the patients whether they had been previously diagnosed with bipolar or manic-depressive disorder by a health care professional. Family history information was obtained from the patient regarding first-degree relatives. Diagnoses were blind to the results of the self-administered scale. The study was conducted from May 2001 to March 2005.
Fewer than half the patients who reported that they had been previously diagnosed with bipolar disorder received a diagnosis of bipolar disorder based on the SCID. Patients with SCID-diagnosed bipolar disorder had a significantly higher morbid risk of bipolar disorder than patients who self-reported a previous diagnosis of bipolar disorder that was not confirmed by the SCID (p < .02). Patients who self-reported a previous diagnosis of bipolar disorder that was not confirmed by the SCID did not have a significantly higher morbid risk for bipolar disorder than the patients who were negative for bipolar disorder by self-report and the SCID.
Not only is there a problem with underdiagnosis of bipolar disorder, but also an equal if not greater problem exists with overdiagnosis.

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    • "The onset of bipolar disorder (BD) involves a major depressive episode (MDE) in approximately half of type-I (BD-I) patients, and three-quarters of those diagnosed type-II (BD-II) (Baldessarini et al., 2013; Goodwin and Jamison, 2007; Koukopoulos et al., 2013; Tondo et al., 2014). Nonetheless, studies carried out in psychiatric and primary care settings have found that BD is sometimes underrecognized , particularly in patients presenting for treatment of depression (Ghaemi et al., 2000Ghaemi et al., , 2002 Hantouche et al., 1998; Zimmerman et al., 2008). Even for those patients diagnosed with BD, the time lag between initial treatment seeking and correct diagnosis often exceeds 10 years (Coryell et al., 1995; Hirschfeld et al., 2000; Lish et al., 1994). "
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    ABSTRACT: To assess the psychometric properties of the Italian adaptation of the Hypomania-Check-List 32-item, second revision (HCL-32-R2) for the detection of bipolarity in major depressive disorder (MDD) treatment-seeking outpatients. Methods: A back-to-back Italian adaption of the “Bipolar Disorders: Improving Diagnosis, Guidance, and Education” English module of the HCL-32-R2 was administered between March 2013 and October 2014 across twelve collaborating sites in Italy. Diagnostic and Statistical Manual Fourth edition (DSM-IV) diagnoses were made adopting the mini-international neuropsychiatric interview, using bipolar disorder (BD) patients as controls. Results: In our sample (n=441, of whom, BD-I=68; BD-II=117; MDD=256), using a cut-off of 14 allowed the HCL-32-R2 to discriminate DSM-IV-defined MDD patients between “true unipolar” (HCL-32-R2-) and “sub-threshold bipolar depression” (HCL-32-R2+) with sensitivity=89% and specificity=79%. Area under the curve was .888; positive and negative predictive values were 75.34% and 90.99% respectively. Owing to clinical interpretability considerations and consistency with previous adaptations of the HCL-32, a two-factor solution (F1=”hyperactive/elated” vs. F2=”irritable/distractible/impulsive”) was preferred using exploratory and confirmatory factor analyses, whereas items n.33 (“I gamble more”) and n.34 (“I eat more”) introduced in the R2 version of the scale slightly loaded onto F2 and F1 respectively. Cronbach’s alpha=.88 for F1 and .71 for F2. Limitations: No cross-validation with any additional validated screening tool; treatment-seeking outpatient sample; recall bias; no systematic evaluation of eventual medical/psychiatric comorbidities, current/lifetime pharmacological history, neither record of severity of current MDE. Conclusions: Our results seem to indicate fair accuracy of HCL-32 as a screening instrument for BD, though replication studies are warranted.
    Full-text · Article · Mar 2015 · Journal of Affective Disorders
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    • "The onset of bipolar disorder (BD) involves a major depressive episode (MDE) in approximately half of type-I (BD-I) patients, and three-quarters of those diagnosed with type-II (BD-II)1234. Nonetheless, studies carried out in psychiatric and primary care settings have found that BD is sometimes under-recognized, particularly in patients presenting for treatment of depression5678. Even for those patients diagnosed with BD, the time lag between initial treatment seeking and correct diagnosis often exceeds 10 years91011. "
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    ABSTRACT: To assess the psychometric properties of the Arabic adaptation of the Hypomania-Check-List 32-item, second revision (HCL-32-R2) for the detection of bipolarity in major depressive disorder (MDD) inpatients suffering a current major depressive episode (MDE). The "Bipolar Disorders: Improving Diagnosis, Guidance, and Education" Arabic module of the HCL-32-R2 was administered to mother-tongue Arabic MDE inpatients between March 2013 and October 2014. Diagnostic and Statistical Manual Fourth edition (DSM-IV) diagnoses were made adopting the mini-international neuropsychiatric interview, using bipolar disorder (BD) patients as controls. In our sample (n=500, of whom, BD-I=329; BD-II=70; MDD=101), using a cut-off of 17 allowed the HCL-32-R2 to discriminate DSM-IV-defined MDD patients between "true unipolar" (HCL-32-R2(-)) and "sub-threshold bipolar depression" (HCL-32-R2(+)) with sensitivity=82% and specificity=77%. Area under the curve was .883; positive and negative predictive values were 93.44% and 73.23% respectively. Owing to clinical interpretability considerations and consistency with previous adaptations of the HCL-32, a two-factor solution (F1="hyperactive/elated" vs. F2="irritable/distractible/impulsive") was preferred using exploratory and confirmatory factors analyses. Item n.33 ("I gamble more") and n.34 ("I eat more") introduced in the R2 version of the HCL-32 loaded onto F1, though very slightly. Cronbach's alphas were F1=.86 and F2=.60. No cross-validation with any additional validated screening tool. Inpatients only sample; recall bias; no systematic evaluation of eventual medical/psychiatric comorbidities, current/lifetime pharmacological history, or record of severity of current MDE. In our sample, the HCL-32 fairly discriminated between MDD and BD-I but not BD-II, therefore soliciting for replication studies for use in Arabic-speaking depressed inpatients. Copyright © 2015. Published by Elsevier Inc.
    Full-text · Article · Mar 2015 · Comprehensive Psychiatry
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    • "Diagnostic challenges can emerge, particularly in the context of BD II and BPD [32]. Specifically, some authors have proposed that BPD may be a misdiagnosis in patients with bipolar spectrum conditions [33] [34] [35], while others argue that BPD would be better conceptualized as an atypical variant of a mood disorder [36] [37] [38] [39] [40] [41]. Contemporary diagnostic manuals including DSM-5 describe these disorders as distinct entities in separate sections of the manual, with clear differences in terms of prevalence, outcomes and course of illness [2,42–44]. "
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    ABSTRACT: Objectives: Clinical studies suggest a high co-morbidity rate of borderline personality disorder (BPD) with bipolar disorder (BD). This study examines the prevalence and correlates of BPD in BD (I and II) in a longitudinal population-based survey. Methods: Data came from Waves 1 and 2 (Wave 2: N = 34,653, 70.2% cumulative response rate; age ≥ 20 years) of the National Epidemiologic Survey on Alcohol and Related Conditions (NESARC). Lay interviewers conducted in person interviews using the Alcohol Use Disorders and Associated Disabilities Interview (AUDADIS-IV), a reliable diagnostic tool of psychiatric disorders based on DSM-IV criteria. Subjects with BD I (n = 812), BD I/BPD (n = 360), BD II (n = 327) and BD II/BPD (n = 101) were examined in terms of sociodemographics, mood, anxiety, substance use and personality disorder co-morbidities and history of childhood traumatic experiences. Results: Lifetime prevalence of BPD was 29.0% in BD I and 24.0% in BD II. Significant differences were observed between co-morbid BD I/II and BPD versus BD I/II without BPD in terms of number of depressive episodes and age of onset co-morbidity, and childhood trauma. BPD was strongly and positively associated with incident BD I (AOR = 16.9; 95% CI: 13.88-20.55) and BD II (AOR = 9.5; 95% CI: 6.44-13.97). Conclusions: BD with BPD has a more severe presentation of illness than BD alone. The results suggest that BPD is highly predictive of a future diagnosis of BD. Childhood traumatic experiences may have a role in understanding this relationship.
    Full-text · Article · Jan 2015 · Comprehensive psychiatry
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